Long-Term Graft Survival Following Penetrating Keratoplasty in Eyes with Preoperative Corneal Neovascularization.

INTRODUCTION: We aimed to evaluate long-term graft survival following penetrating keratoplasty (PKP) in eyes with preoperative corneal neovascularization (CorNV), and to assess the impact of the extent of CorNV on graft outcomes. METHODS: This was a retrospective longitudinal study. Patients with preoperative CorNV who underwent PKP between 2003 and 2024 were included. Demographics, underlying pathology, and CorNV stage (clock-hour extent) and depth were recorded at baseline before PKP. Visual acuity and endothelial cell density (ECD) were assessed during follow-up. Kaplan-Meier survival analysis and Cox proportional hazards models were used to identify risk factors for graft failure. Graft failure was set as primary outcome. RESULTS: A total of 80 eyes were included (mean age 55 ± 16 years; 42 male, 53%; 38 female, 47%). Moderate to severe CorNV (> 3 clock-hours) showed no significant association with increased graft failure risk (HR 1.51; p = 0.31). Survival was mainly influenced by etiology: patients with Acanthamoeba keratitis had significantly better outcomes than those with burns (HR 11.02; p = 0.032). One-year visual acuity improved notably. CorNV depth was not linked to graft survival. CONCLUSIONS: In this cohort, preoperative CorNV extent was not significantly associated with graft failure after PKP; outcomes depend largely on the underlying etiology. Thorough assessment of CorNV features and etiology is advised to refine risk stratification. Standardized imaging and multicenter studies are needed to clarify additional prognostic factors and further improve management.